Obesity and high-fat diet (HFD) are risk
factors for multiple types of cancer. Compelling evidence indicates that
obesity
and diet also play a role after the diagnosis of cancer,
influencing treatment, tumor progression, overall well-being and
survival. Previously we reported that obesity is associated
with increased overall survival in lung cancer patients. Others
have shown that HFD was protective in murine MAC16 cachexia.
Based on those data and similar obesity risk paradox observations
in other diseases, we posited that obesity or HFD might
provide increased physiological reserve and slow cachexia in cancer.
Here we sought to determine whether diet induced obesity
(DIO) or HFD were protective in the Lewis Lung carcinoma mouse model
of cancer cachexia. DIO obese and C57Bl/6J lean mice were
fed a HFD (60 % kcal from fat), while another lean group was fed
normal chow (LFD) (10 % kcal from fat). Mice were
inoculated with tumor cells and euthanized 17 and 23 days later.
Both obese
and lean tumor-bearing mice fed HFD showed increased loss of
total body mass, skeletal muscle and fat mass compared with
tumor-bearing
mice fed LFD. This increased muscle wasting in DIO and HFD
mice was associated with greatly reduced plasma insulin and adiponectin
levels and increased levels of pro-inflammatory cytokines
IL-6 and LIF versus LFD tumor-bearing controls. In DIO mice, plasma
growth factor/cytokine changes corresponded to decreased
muscle pAKT and pFOXO3a, and increased pSTAT3 levels, while pSMAD2
and NF-kB levels were unchanged. Taken together, these
changes would inhibit anabolism, promote catabolism and drive the
inflammatory
phenotype, thus contributing to enhanced muscle wasting. In
conclusion, our data suggest that both obesity, as a pre-existing
condition, and high-fat diet consumption result in worsening
of muscle wasting induced by tumor. Furthermore, neither increased
body mass nor HFD were protective in experimental cancer
cachexia.

Effect of Enobosarm on Physical Function in Cancer Patients with < or ≥5 % Weight Loss in a Phase IIb Trial

Objectives: Although cachexia has been defined as
>5 % weight loss, limited data exists on prevention and
treatment of muscle wasting
prior to becoming cachectic. Cancer-induced muscle wasting
begins early resulting in decline in physical function and other
detrimental consequences.

Methods: We conducted a randomized, double-blind, placebo-controlled study to evaluate enobosarm’s effect on physical function and
muscle wasting. Subjects (n = 159) received enobosarm
or placebo for 16 weeks. Subjects were males >45 y and
postmenopausal females, with ≥2 % weight
loss in the past 6 months and NSCLC, CRC, CLL,
non-Hodgkin’s lymphoma or breast cancer. We report on changes in
physical function
based on weight loss of </≥5 % in the 6 months
prior to randomization.

Conclusions: Enobosarm was well tolerated and showed
statistically significant improvement in physical function regardless of
baseline
weight loss. This provides evidence that enobosarm may play
an important role in the management of cancer patients by treating
and preventing decline in physical function and muscle
wasting before a patient becomes cachectic.

Appetite regulation is frequently disturbed
in cancer patients, often leading to anorexia. It is difficult to
understand processes
important in the development of anorexia, because anorexia
is often accompanied by cachexia.

In this study, we report on hypothalamic gene
expression profile of a cancer cachectic model with increased food
intake. In
this model, appetite regulating systems, that fail in
anorexia, are able to adapt properly to changes in energy balance. By
comparing these findings to changes in anorectic cachectic
mice, we can distinguish between common mediators involved in cachexia
and processes specifically important for cancer-induced
eating disorders

Expression of the orexigenic genes NPY and
Agrp increased, whereas expression of anorexigenic CCK and GLP1
decreased in TB
mice. PomC expression was not changed. Top 20 of
up-regulated genes consisted of inflammatory genes such as lipocalin2,
leucin-richα2-glycoprotein1
and oncostatin M receptor and food intake mediators such as
growth hormone, oxytocin and Agrp.

Conclusion: Genomic analysis of the hypothalamus of
C26-TB mice with increased food intake showed changes in NPY, Agrp and
serotonin
signaling. These changes in appetite-regulating systems are
likely to explain compensatory eating behaviour of mice bearing
C-26 tumour. Targeting these systems is a promising strategy
to avoid the development of cancer-induced anorexia.

Effect of ghrelin agonists on muscle mass and function: synergism with exercise

Following a search of the existing patents on
the market, we identified 16 pro-anabolic drugs including ghrelin
agonists.
We have reviewed the central and peripheral mechanisms of
ghrelin and we are proposing a possible synergistic coupling with
exercise, which could potentially enhance and maximize the
physiological effects of these agonists. The initial physiological
mechanism that controls muscle anabolism following the
activation of the ghrelin receptor in the CNS involves the release
of growth hormone/insulin-like growth factor-1 (GH/IGF-1).
IGF-1 is an important anabolic hormone that has a specific receptor
on the muscle membrane responsible for cell growth. However,
clinical experience suggests that IGF-1 alone is not sufficient
to induce significant muscle hypertrophy, but that the
permissive effect of regular physical exercise can potentiate the
anabolic
effect of this protein. The stimulus of dynamic muscle
contraction induces the secretion of muscle-restricted IGF-1 (mIGF-1)
that enhances protein synthesis, increases lean body mass,
and eventually leads to the improvement of muscle strength. Physical
exercise also exerts a positive feedback on the
hypothalamus-hippocampus circuit. More specifically, the effects of
ghrelin
agonists have been shown to create a crosstalk between the
activated growth hormone secretagogue receptor type 1a (GHSR-1a)
membrane receptor in pituitary neurons and the regulation of
Neuropeptide Y (NPY) gene expression. NPY is considered to be
among the most important hormones in the central regulation
of energy balance. NPY is secreted by the hypothalamus and, in
addition to increasing food intake, it increases the
proportion of energy stored as fat and blocks nociceptive signals to
the brain. NPY acts as an antagonist of the corticosteroid
effect in the hippocampus, promoting central adaptation to an
environmental
stress. The synergy between ghrelin agonists and physical
exercise may act together to potentiate the release of endorphins
and endocannabinoids, both of which tend to decrease the
sensation of fatigue.

Enteral nutrition improves micronutrient status but fails to improve protein intakes in patients with cancers of the head
and neck

1Alberta Institute for Human Nutrition, Faculty of Agriculture, Life and Environmental Sciences, University of Alberta, Edmonton,
Alberta;2Department of Surgery (Thoracics), Alberta Health Services, Edmonton, Alberta;3Dept. Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta,4Faculty of Nursing, University of Alberta, Edmonton, Alberta

Background: Patients with cancers of the head and neck (HNC) are at high risk for malnutrition and may be deficient in several nutrients
simultaneously.

Objective: To compare intakes of folate, zinc, vitamins D and E, and protein in HNC patients consuming self-selected foods. Intakes
at various points in the disease trajectory were compared to ESPEN guidelines (ESPEN-g) for cancer patients.

Conclusion: Dietary interventions in HNC patients must consider the complete range of deficiencies observed throughout treatment. EN
may not be adequate in meeting the nutritional needs of this population, most notably in protein intake.

Protein and energy intake at recommended levels does not prevent weight loss in head and neck cancer patients

Background: Patients with cancers of the head and neck (HNC) are at high risk for malnutrition. Information regarding the extent to which
these patients meet protein and energy recommendations at various stages of the cancer trajectory is limited.

Objective: To relate energy and protein intakes at diagnosis, during and after radiotherapy treatment (RT) to weight loss in orally-fed
HNC patients.

Methods: HNC patients (n = 38) undergoing RT
were prospectively evaluated and completed 3-day food records at
diagnosis, after 6 weeks of RT, and
at post-RT (follow-up). At each time point, body weight and
BMI were recorded; energy and protein intakes were calculated
and compared to the ESPEN guidelines of
30–35 kcal/kg/day and 1.2–2 g protein/kg/day.

Results: The majority of patients lost >10 %
of total body weight (range 0.5–25 %) from diagnosis to follow-up.
At diagnosis, patients
consumed an average of 1.3 g protein/kg/day, declining
to 0.9 g protein/kg during treatment and improving at follow-up to
1.5 g protein/kg. Mean energy intakes fell from
30 kcal/kg/day at diagnosis to 23 kcal/kg/day
(3.7–84.2 kcal/kg/day) during
treatment, and increasing to 30 kcal/kg/day at
follow-up. Mean weight loss of patients with protein intakes ≤1.2 g
protein/kg/day
at baseline (45 %) through treatment was 11 kg
(range 0.6–24.5 kg). Although 32 % of patients met or exceeded
energy intakes
during treatment, 75 % of these patients experienced a
mean weight loss of 10 kg (0.6–24.5 kg). Ninety percent of
patients
who met or exceeded the minimum 1.2 g/kg/day
recommended protein intake during treatment (32 %) lost weight.
Despite a restoration
of protein and energy intake following treatment, patients
continued to lose weight.

Conclusion: Consumption of calories and protein at recommended levels does not prevent weight loss in HNC. Evaluation of guidelines for
nutritional support in HNC would be valuable.

1University of Edinburgh, Clinical and Surgical Sciences (Surgery), Royal Infirmary, Edinburgh, UK;2Faculty of Medicine, Clinical Department of Cancer
Research and Molecular Medicine, Norwegian University of Science and
Technology
(NTNU), Trondheim, Norway;3Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada;4Department of Oncology (Division of Palliative Care Medicine), University of Alberta, Edmonton, Alberta, Canada;5Faculty of Medicine, Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and
Technology (NTNU), Trondheim, Norway

Aim: To utilise a candidate gene approach to study the potential association between host genome and the presence of cachexia
defined by sarcopenia and weight loss in cancer patients.

Methods: Based on a systematic review, 129 SNPs in 80
genes were analysed for an association with cachexia in 222 patients
recruited
at first presentation to a surgical or oncology clinic.
Diagnostic CT scans were used to define sarcopenia by using a thoracic
(T4) or lumbar (L3) vertebral marking to derive a skeletal
muscle index. Percentage weight loss was calculated from weight
measured at recruitment and pre-morbid weight recalled.
Association testing was adjusted for age, sex, tumour type, BMI and
stage. Unconditional logistic regression was use to
calculate odds ratios (OR) and their 95 % confidence intervals
(95 % CI)
for the minor allele of individual SNPs and its association
with the proposed cachexia phenotype. The study had 80 % power
to detect an odds ratio of 1.5 in SNPs with a minor allele
frequency (MAF) of >20 %.

Conclusions: This preliminary study provides some
significant SNP associations with a robust phenotype of cancer cachexia
based on CT
analysis. Of the two most significant SNPs found firstly,
rs4280262 in the LITAF gene is a missense mutation which may lead
to a change in function in regulating transcription of
specific genes involved in cancer cachexia. Secondly, the C allele
of the SNP rs10636 in the MT2A gene is associated with
alteration in the homeostasis of intracellular zinc, a critical
component
of an anti-oxidant system against cellular damage which
may lead to a predisposition to develop cancer cachexia.

CHR

Gene

SNP

Risk allele

Population frequency

Odds ratio

95 % CI

Permutated P value

16

LITAF

rs4280262

G

82 %

0.4028

0.3946–0.4111

0.003787

16

MT2A

rs10636

C

25 %

2.019

1.98–2.058

0.01982

1

VCAM1

rs3176860

G

43 %

1.813

1.783–1.843

0.02778

18

LPIN2

rs3745012

T

64 %

0.5013

0.4917–0.5111

0.0404

4

TLR2

rs3804099

C

43 %

0.5693

0.5592–0.5797

0.04372

Table 1

Ubiquitin-proteasome system is not enhanced in skeletal muscle of advanced non-small cell lung cancer patients with cachexia

1The School of Biomedical Sciences, The University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH, United Kingdom; 2Department of Palliative Medicine, The University of Nottingham, Nottingham University Hospitals NHS Trust, Nottingham, NG5
1PB, United Kingdom

Introduction: The unintended loss of skeletal muscle
is common in patients with advanced non-small cell lung cancer (NSCLC),
and this contributes
to the high mortality and morbidity of this group.
Experimental models of cancer cachexia suggest that enhanced
ubiquitin-proteasome
(UP) mediated protein breakdown is predominantly responsible
for the loss of muscle mass. This has yet to be observed in NSCLC
patients, but only those in a pre-cachectic state have been
included in studies performed to date. Thus, UP-mediated proteolysis
may still be important in later stages once cachexia is
evident.

Methods: To test this, 4 NSCLC patients with locally
advanced or metastatic disease meeting recommended criteria for cancer
cachexia
were recruited along with 4 age, sex and smoking-history
matched control subjects. Following an overnight fast, a biopsy was
taken from the vastus lateralis muscle to assess TNFα, IL-6,
MAFbx and MuRF1 mRNA levels by qPCR; protein levels of MAFbx,
MuRF1 and proteasome subunits α1-3, 5-7 (PSMA1-3, 5-7) by
western blot and chymotrypsin-like activity of the proteasome. A
blood sample was obtained for assessment of TNFα and IL-6 by
ELISA.

Skeletal muscle catabolic signaling has a
well-established function in the disruption of protein turnover during
cancer cachexia;
while the regulation of anabolic suppression warrants
further investigation. ApcMin/+ mice undergo IL-6 dependent cachexia,
and systemic IL-6r antibody administration attenuates
cachexia without improving muscle protein synthesis. Treadmill exercise
can prevent IL-6 induced cachexia in ApcMin/+ mice, but it
is not certain if skeletal muscle anabolic signaling is enhanced.
The purpose of this study was to determine if cachectic
skeletal muscle maintained anabolic plasticity related to mTOR signaling
in response to insulin activation and how IL-6/STAT3
signaling would affect this plasticity. We also determined if treadmill
exercise training would improve muscle mTOR signaling in
ApcMin/+ mice. ApcMin/+ mouse muscle mTOR signaling was examined
in response to either glucose administration or varying
levels of systemic IL-6 over-expression. IL-6 induced STAT3 signaling
was examined C2C12 myotubes with or without insulin
stimulation. The effect of treadmill exercise (EX;18 m/min,
1 h, 6 days/week,
5 % grade) on IL-6 induced suppression of muscle mTOR
signaling was examined in ApcMin/+ mice. Cachexia reduced both basal
mTOR signaling, and mTOR responsiveness to glucose
administration. ApcMin/+ mice systemically over-expressing IL-6 showed
a dose dependent suppression of mTOR signaling, that was
rescued by treadmill exercise training independent of muscle STAT3
activation. IL-6 treated myotubes demonstrated suppressed
mTOR signaling and increased catabolic signaling, which included
FoxO3a and AMPK activation. The IL-6 induced suppression of
mTOR and activation of AMPK in myotubes was independent of STAT-3
signaling. Insulin stimulated mTOR activity in myotubes was
not affected by IL-6 treatment. Besides a dose dependent suppression
of muscle mTOR activity by IL-6, our data demonstrates that
cachectic muscle has a reduction in mTOR responsiveness to glucose
stimulation. Although IL-6 can directly inhibit mTOR
signaling in myotubes, STAT3 activation does not appear necessary for
this inhibition. Lastly, treadmill exercise training can
block IL-6 induced suppression of muscle mTOR signaling ApcMin/+
mice.

The psychological and social consequences of cachexia in patients with advanced cancer: a systematic review

Joanne Reid, Olinda Santin, Sam Porter

School of Nursing and Midwifery, Queen’s University Belfast, Northern Ireland

Introduction: Cachexia affects up to 80 % of
terminally ill cancer patients. Cachexic patients struggle with poor
appetite and severe weight
loss and this has a holistic negative impact across
biological, psychological and social domains.

Aim: The aim of this systematic literature review is to describe the psychological and social consequences of cachexia for patients
with advanced cancer.

Methods: Databases including Medline, Pub Med and Psych info were searched systematically from inception to identify studies that
have examined the psychosocial impact of cancer cachexia.

Findings: From 103 abstracts, 11 studies were
eligible for review. A number of key themes were identified that were
described
as having a psychological or social impact on cachexic
patients. The psychological impact of cancer cachexia included distress,
anxiety, depression and body image concerns. The main social
themes identified were social exclusion and conflict over food.
The inability to eat and the associated weight loss often
causes conflicts within relationships which can result in the patient
socially excluding themselves. As a result of this conflict
patients feel forced to eat or feel that they must force themselves
to eat. Research conducted which alludes to the psychosocial
implications of cancer cachexia, highlights that patients want
more appropriate supportive health care interventions in
relation to this syndrome and its impact.

Conclusions: Cancer cachexia has severe psychosocial
implications for patients. There appears to be a mismatch between the
issues reported
by patients and the available supports to meet these needs.
There is a need for appropriate supportive health care interventions
to be developed to help patients manage their psychosocial
concerns.

Prevalence and Impact of Hypogonadism in Cancer Patients with Muscle Wasting in a Phase IIb Enobosarm Trial

Objectives: Hypogonadism is associated with weight
loss and poor outcomes in cancer patients. Up to 50 % of males with
advanced cancer
are hypogonadal at presentation or during treatment. Wasting
in cancer patients is also associated with decline in physical
function and performance status. We conducted a randomized,
double-blind, placebo-controlled study to evaluate enobosarm’s
effect on muscle wasting and physical function.

Conclusions: Hypogonadism is common in male cancer
patients and is correlated with weight loss and diminished physical
function. In this
trial, enobosarm improved physical function in hypogonadal
and eugonadal men despite poorer baseline physical function in
hypogonadal patients. This provides evidence that enobosarm
may play an important role in the management of cancer-related
muscle wasting.

Results: The switch between Notch (proliferation) and
Wnt (differentiation) signaling pathway appears to be dysfunctional
leading
to a pro-proliferative state suggested by the increased
expression of MyoD, Myf5, GSKα/β and phospho-Numb in patients with
COPD (MTCSA <70 cm2). Satellite cell numbers were similar between groups. The number of central nuclei per 100 fibers was increased in patients
with COPD (MTCSA >70 cm2) compared to patients with COPD (MTCSA <70 cm2)
and controls. In COPD, a decreased in the proliferation of satellite
cells was initially observed in vitro at 48 h while
their number was increased at 96 h compared to
controls. During myogenesis, an altered pattern of MRFs (Pax7, Myf5 and
Myogenin)
accumulation was observed between patient with COPD and
patient with normal lung function. Finally, accumulation of the myosin
heavy chain protein was reduced during myogenesis.

Conclusions: Based on these results, the transition
between the Notch and the Wnt pathway seems to be defective maintaining
satellite
cells into a proliferative state. Deficiencies in their
activation and their myogenic program could contribute to the
maintenance
or the development of muscle atrophy in this population.

Dept. of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Dept.
of Urology, St. Olav’s University Hospital, Trondheim, Norway

Although anorexia represents an important
factor in the development of cachexia, it by no means accounts for it.
It seems
evident that metabolic disturbances present in the cancer
patient have a definitive role in the development of cachexia. Advanced
human bladder cancer is commonly associated with the
development of cachexia, as is the case for rodent models. However,
comprehensive
metabolic monitoring of human cancer patients is hardly
feasible and little data on animal models are available. The purpose
of the present study was to establish metabolic profiles of
rats with progressive bladder cancer.

The orthotopic rat bladder cancer model was
established by exposing male Fischer-344 rats to
4-hydroxy-butyl(butyl)nitrosamine
(BBN) in drinking water for 12 weeks. These animals
were followed for approximately 1 year for signs of cachexia
(10 % weight
loss), body composition using dual-energy X-ray
absorptiometry (DXA) in 12 animals was analysed at 100 % weight and
after
10 % weight loss. Eating behaviour and metabolic
parameters was obtained using comprehensive animal monitoring system
(CLAMS).

Cachexia does occur in a rat model for
orthotopic bladder cancer. In spite of relatively low tumour load
significant changes
are noted in both body composition and metabolism. In spite
of significant fat compartment reduction, the respiratory exchange
ratio was not reduced.

Considering a minimal tumour load, this may
suggest a systemically increased TCA cycle flux leading to increased
glucose consumption
(the so-called “Warburg” effect).

The behaviour of the peptides leptin and ghrelin, PYY, NPY, CART and MSH in gastric cancer patients

Background: Peptides that regulate food intake have
been studied and associated to some types of cancers. Generally, gastric
cancer patients
tend to be cachetic with low body mass index (BMI), since
most of them have gastrointestinal symptoms such as a nausea and
anorexia. The aim of this study was to investigate, in
gastric cancer patients, the behaviour of some peptides that regulate
food intake.

Methods: Serum ghrelin, leptin, PYY, NPY, AgRP, CART and MSH levels were measured by ELISA (enzyme linked immuno-sorbent assay). BMI
and weight loss, were determined in all subjects studied. The patients had been classified in 3 groups: cachetic group(gastric cancer patients in treatment that are considered cachetic according to Fearon, 2010); non-cachetic group (these gastric cancer subjects had already done the cancer treatment and are gaining weight; the third group consisted on health
controls.

Results: among the 127 subjects studied, 19 were in the cachetic group (47 % underweight and 21 % overweight); 28 in the non-cachetic and 80 as health control. PYY, NPY and CART levels were lower in cachetic group followed by non-cachetic. Ghrelin levels, in contrast were lower in the health group (p < 0.001). Leptin, AgRP and MSH did not show any difference between all groups.

Conclusion: Leptin, MSH and AgRP concentrations did
not show any difference in gastric cancer patients (cachetic and
non-cachetic). Despite
of gastric surgery ghrelin levels were still higher in
cachetic group followed by non-cachetic. The concentrations of PYY
and NPY were lower while ghrelin were higher in cachetic
group suggesting a possible mechanism of reversing the cachexia process.

Background: Obesity is a significant cause of
mortality and diseases like cancer. On the other hand, cachexia, or
pathologic weight loss,
is a significant problem. Despite their differences, both
processes involve neuropeptides and hormones that regulate food
intake and energy expend. Alterations in this mechanism can
lead to obesity or anorexia. Thus far, these peptides have mainly
been studied in animal models but not in cancer people. The
present study aimed to assess the behaviour of anorexigenic and
orexigenic neuropeptides and peripheral signals (Ghrelin,
PYY, NPY and AgRP) in colorectal cancer patients compared to a healthy
group.

Material and methods: 164 subjects were enrolled into
the study: 84 with colorectal cancer and 80 healthy controls. The
peptides and the neuropeptides
were measured by enzyme linked immuno-sorbent assay (ELISA)
method in all subjects.

Results: PYY, NPY and AgRP were lower in the Cancer
group. In underweight subjects the results were the same but we did not
find differences
between AgRP levels among the groups (p = 0.181). Between normal weight and overweight we found differences in all groups with lower levels in Cancer group.

Conclusions: Ghrelin levels were higher in colorectal
cancer patients despite of BMI. PYY and NPY seem to have the same
regulation and
not to be influenced by the BMI. AgRP concentration
increased significantly only in the underweight cancer group. The most
important finding was that ghrelin were always higher in
cancer group despite of body mass index.

Background: Leptin, anorexigenic hormone involved in
body mass regulation, might play a role in cancer cachexia development.
Hormones
produced by adipocytes are associated with cancer
progression. Elucidating the mechanisms by which obesity may increase
cancer
risk may lead to the identification of treatment and also
prevention targets. We aimed to compare the leptin serum levels
in colorectal cancer patients and healthy individuals and
also to correlate leptin concentration with body mass index.

Methods: Eighty-four patients with colorectal cancer
and 80 healthy controls were enrolled and subdivided according to their
BMI in
underweight, normal weight or overweight. Serum leptin
levels were measured as ng/ml by enzyme linked immuno-sorbent assay
(ELISA) method in all subjects.

Results: There were no differences in gender and age. Serum leptin concentration of underweight cancer group was significantly lower
than underweight controls (4.79 ± 3.9 vs. 22.3 ± 21.8) (p = 0.005). On the other hand, on overweight cancer group were higher compared to overweight control (24.8 ± 29 vs. 10.5 ± 15)
(p = 0.022). Between normal weight cancer group and health individuals there were no differences (p = 0.550). Comparing cancer group to the control group, without consider the BMI, we did not find any difference (p = 0.229).

Conclusion: Our results showed that leptin may play a
role in development and progression of colorectal cancer in obese
subjects but
in underweight. If leptin is produced by adipocytes, those
results suggest that in cancer patients the fat free mass is higher
probably due to a fat mass depletion priority.

1Department of Nutrition and Dietetics, VU University Medical Center, Amsterdam, The Netherlands. 2Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands

Background and aims: The definitions and cut-off
points of different subtypes of malnutrition (e.g. (pre)cachexia,
sarcopenia) are currently in
the center of attention in international cancer literature.
The aim of this study was to assess the prevalence of different
markers of poor nutritional status in patients with advanced
cancer scheduled for chemotherapy.

Background and aims The diagnostic framework of
cancer cachexia is currently in the center of attention in international
cancer literature. Consensus
is reached on the component weight loss in combination with
Body Mass Index (BMI) and low muscle mass1 but not on other
potential cachexia features, for example inflammation and anorexia. The
aim of this study is to assess the
prevalence of other potential features of (pre)cachexia in
cachectic and non-cachectic patients with advanced cancer scheduled
for chemotherapy.

Results Data were obtained for 122 patients
(63.3 ± 10.5 y, 56 % male) with cancer: 42 % lung,
25 % colorectal, 20 % prostate and
13 % breast. Sixty-six patients (54 %) reported
any weight loss before start of chemotherapy, whereas still 50 %
had a BMI
>25 kg/m2. Forty-one patients (34 %)
were cachectic. A low FFMI and anorexia according to the FAACT
questionnaire were more prevalent
in cachectic patients compared to patients without cachexia
(Chi2 tests, P < 0.01 and P = 0.04,
respectively, Table 1). But also a number of patients without cachexia
had signs of a poor nutritional status, anorexia
or inflammation, which could be signs of precachexia.
However, only 6 patients were precachectic according to the consensus
definition2. Moreover, there was no correlation between CRP and anorexia (Pearson r: −0.09, p = 0.38 for CRP and FAACT and r: −0.03, p = 0.75 for CRP and VAS).

* no reference values available for patients with a BMI <18.5 (n = 1 for no cachexia and n = 4 for cachexia)

Conclusions Thirty-four percent of patients with
advanced cancer were cachectic before start of chemotherapy. A poor
nutritional status
was also prevalent in patients without cachexia, but only 6
patients were precachectic. We found no correlation between inflammation
and anorexia, which substantiates the complexity of the
diagnosis of (pre)cachexia.

1Cancer Research Group, Departament de Bioquímica i
Biologia Molecular, Facultat de Biologia, Universitat de Barcelona,
Barcelona,
Spain.2Institut de Biomedicina de la Universitat de Barcelona, Barcelona, Spain

The aim of the Animal CAchexia SCOre (ACASCO)
is to overcome the problem of cachexia staging in experimental animals.
The
score considers five main different factors involved in the
patophysiology of cachexia: body weight and lean body mass loss
(BWC), inflammatory, immunological and metabolic
disturbances (IMD), anorexia (ANO), physical performance (PHP) and
quality
of life (QoL). The score’s scale classifies cachexia in 4°:
mild, moderate, severe and terminal phase.

In the study, we analyzed the above-mentioned factors in Yoshida AH-130 ascites hepatoma model at different days after the
tumour inoculation: 2, 4, 6, 8, 10 and 11.

The analysis of all these components allow
the classification of the cachexia degree in this tumour model:
tumour-bearing
(TB) animals 2 days after the tumour inoculation have
been classified as pre-cachexia, TB animals 4 days after the tumour
inoculation: mild cachexia, TB animals 6 days after the
tumour inoculation: moderate cachexia, TB animals 8 and 10 days
after
the tumour inoculation: severe cachexia and TB animals
11 days after the tumour inoculation: terminal cachexia.

The present score facilitates cachexia
staging in Yoshida AH-130 ascites hepatoma model. ACASCO could be an
useful tool for
the evaluation of cachexia in other experimental tumours
allowing for a more appropriate measurement of the degree of cancer
wasting.

Role of vitamin D in the pathogenesis of cancer-induced muscle wasting

Cancer cachexia is a syndrome characterized
by loss of skeletal muscle protein, depletion of lipid stores and
hormonal perturbations.
Vitamin D (VitD) has been recently proposed as a potential
regulator of skeletal muscle mass since several studies described
a relationship between muscle weakness/wasting and VitD
deficiency.

Preliminary data obtained in our laboratory
indicated a significant decrease in circulating VitD in rats bearing the
AH-130
hepatoma compared to controls. On this line, the aim of the
present study was to investigate the involvement of VitD deficiency
in the pathogenesis of muscle wasting in the AH-130 hosts.

The animals were divided into four
experimental groups: controls, AH-130, vitD-treated and AH-130
vitD-treated. 25-OH VitD
was given per os daily (40 IU/day/kg initial body
weight, dissolved in corn oil). Untreated groups received vehicle alone.
Treatment started the day of tumor transplantation and the
animals were sacrificed after 7 days. VitD receptor (VDR)
expression
in skeletal muscle was evaluated by RT-PCR.

Both VitD-treated groups (controls and tumor
hosts) showed reduced body weight and decreased gastrocnemius and
tibialis mass
in comparison to the respective untreated groups. VitD
administration also resulted in significant increase of VDR expression
in the muscle of both C and AH-130 rats. VDR was
significantly upregulated in tumor hosts; such a pattern occurs also in
other
cachexia models (mice bearing the C26 or the LLC1 tumors).

Although preliminary, these results
apparently suggest that VitD and VDR-dependent signalling pathway does
not prevent tumor-induced
muscle wasting.

Such observations might be consistent with
results obtained on C2C12 and L6E9 myocyte cultures, where VitD
treatment impaired
myoblast proliferation as well as their complete
differentiation to myotubes. Further experiments (e.g. gain/loss of
function)
are needed to clarify the role of VDR in skeletal muscle
myogenic program.

The metabolic modulator Trimetazidine (TMZ) blocks fatty acid β-oxidation and shifts ATP production towards glucose oxidation,
resulting in improved cell energy metabolism. TMZ is commonly used to treat angina pectoris and has been found to enhance both the efficiency of myocardium metabolism and patient exercise capacity.

TMZ effects on skeletal muscle cells were
investigated in the present study, with particular reference to its
potential protective
effect against atrophy-inducing stimuli. C2C12 myotube
cultures were exposed to serum deprivation or to the proinflammatory
cytokine TNFα. The results show that TMZ significantly
prevents myotube reduction in size caused by both treatments. In
addition
TMZ also markedly increases MyHC expression. Such an effect
is associated with: a) increased levels of phosphorylated S6-kinase,
suggestive of enhanced protein synthesis, and b) activation
of the PI3K-AKT-mTORC2 pathway, and reduction of muscle-specific
ubiquitin ligase mRNA levels, likely inhibiting
proteasome-dependent degradation. Finally, TMZ also induces autophagy in
untreated
myotubes.

In order to study the effectiveness of TMZ
also in vivo, the drug was administered to mice bearing the C26
colon-carcinoma,
a well characterized model of cancer cachexia. Treatment of
tumor hosts with TMZ does not modify food intake, body weight
and muscle mass. By contrast, muscle fiber cross-sectional
area and voluntary muscle grip strength are improved by TMZ; the
latter also correlates with TMZ-induced hypoglicemia,
suggesting that treated animals are effectively using more glucose than
the untreated ones.

On the whole these results, although
preliminary, suggest that TMZ positively interferes with skeletal muscle
cell response
to stress both in vitro and in vivo, supporting a possible
reappraisal of TMZ in the treatment of diseases characterized by
muscle atrophy, among which cancer cachexia.

The Activation Of Signalling Pathways Involved In Muscle Mass Regulation After An Acute Bout Of Resistance Training Exercise
In Patients With Chronic Obstructive Pulmonary Disease

Rationale: Muscle atrophy is an important consequence
of chronic obstructive pulmonary disease (COPD). Information concerning
the use
of resistance training to increase muscle mass in patients
with COPD is sparse and their response to exercise appears to be
suboptimal. A dysregulation in the signaling pathways
involved in the regulation of muscle mass could play an important role
in this phenomenon.

Objective: To investigate the impact of an acute bout of resistance training on key signaling pathways involved in the regulation of
muscle mass in COPD.

Methods: We investigated the phosphorylation status
of key quadriceps signaling proteins (AKT, p70, p38) as well as total
protein
content of Atrogin and MuRF1 before and after an acute bout
of resistant training exercises in 11 patients with COPD (FEV1:
39 ± 2 % of predicted) and 10 age- and activity-matched healthy
controls. All exercises were done at 80 % of max for 2 sets
of 12 repetitions of squat, leg press and leg extension.
Biopsies of the quadriceps were obtained before and 2 h
post-exercise.
The phosphorylated levels of the proteins were analyzed by
western blotting and presented as percent change from baseline.

Results: Post-exercise, the levels of phospho-p70 was increased by 307 ± 119 % in CTRL and by only 120 ± 32 % in COPD (p = 0.03). The levels of phospho-AKT were increased by 228 ± 23 % in CTRL, but were decreased to 89 ± 15 % in COPD (p = 0.02). In addition, phospho-p38 was increased by 130 ± 32 % in CTRL while a reduction to 57 ± 12 % was observed in COPD (p = 0.01).

Conclusion: Overall, our data shows that kinases
associated with hypertrophy (p70, AKT) were lesser phosphorylated in
COPD, while phosphorylation
of p38 was significantly decreased in COPD compared to
controls. These results point toward a potential biochemical mechanism
contributing to the differential training response in COPD.

Time course of atrogenes MurF1 and MAFbx mRNA expression during skeletal muscle atrophy in C2C12 cells

Skeletal muscle atrophy is a common event in
many chronic systemic conditions or diseases such a sepsis, chronic
heart failure,
chronic obstructive pulmonary disease, chronic kidney
disease, diabetes, AIDS and cancer. These conditions may be accompanied
by a complex metabolic syndrome characterized by muscle
wasting, known as cachexia. Molecular pathways responsible for cachexia
are not completely understood, however, pro-inflammatory
cytokines such as Tumor Necrosis Factor (TNF)-α and Interferon (INF)-γ
have a key role in molecular pathways related to loss of
muscle mass and function. Complex mechanisms controlling gene expression
in muscle atrophy may include genes with a common mode of
regulation with deregulated transcript levels over the time course.
We performed a time-series expression analysis of four genes
in differentiated C2C12 muscle cells; in these cells, atrophy
was induced by treatment with TNF-α (10 ng/ml) and
IFN-γ (100 U/ml) at different times (0 h, 6 h, 12 h,
18 h, 24 h, and 48 h).
The dynamic gene expression of MyHC IIa, MyoD, MuRF1, and
MAFbx was measured by Reverse Transcription-Quantitative Real-Time
PCR (RT-qPCR). Our results demonstrated that TNF-α/IFN-γ
treatment decreases MyHC IIa and MyoD gene expression (98 % and
78 %,
respectively) from 0 h to 24 h. However, MyoD mRNA
decay is faster (90 %) compared to MyHC IIa decay (50 %) at
6 h. In addition,
atrogenes MuRF1 and MAFbx show a 2-fold up regulation peak
at 18 h. Our data support the hypothesis that altered gene
regulation
loops occurs within the first 18 h and suggest a common
regulatory program for E3 ubiquitin ligases MurF1 and MAFbx genes.
Results from our study will contribute to the dynamic
description and regulation of gene expression involved in skeletal
muscle
atrophy induced by cytokines.

Systemic inflammation is related with lipid infiltration of muscles in patients with cachexia–related tumors

1Dept. of Medical Oncology, University Hospital of Larissa, Thessaly, Greece;2Dept of Radiology, University Hospital of Larissa, Thessaly, Greece;3Dept of Hematology, University Hospital of Larissa, Thessaly, Greece;4School of Medicine, University of Thessaloniki, Greece

Background: Cancer cachexia is characterized both by
metabolic and structural alterations which lead to physical disability
and adverse
clinical outcomes. In the present study we evaluated the
interrelation between systemic inflammation and lipid infiltration
of muscles (LIM) which may represent an early indication of
muscular degradation and functional deterioration.

Methods: Sixty three patients [52 (82.5 %)
males, median age (range) 66 (40–81)] with metastatic primaries of the
lung [48 (71.2 %)]
and of the upper gastrointestinal (GI) track [15
(23.8 %)] were accrued before the onset of systemic chemotherapy.
Median
body mass index (BMI) (range) was 24 (17–33). The majority
of patients (66.7 %) had an ECOG performance status of 0–1.
C-reactive
protein (CRP) was used as an indicator of systemic
inflammation and was calculated in plasma by standard methods (measured
in mg/L). A CT image at the level of the 3rd lumbar vertebra
(L3) was analyzed for each patient with the use of Slice-O-Matic
software V4.3 (Tomovision, Montreal, Canada) and LIM was
calculated (measured in cm2). Muscle and fat (visceral and subcutaneous)
mass was also assessed. The relations of the aforementioned
variables were subsequently evaluated.

1Dept. of Medical Oncology, University Hospital of Larissa, Thessaly, Greece2Dept of Radiology, University Hospital of Larissa, Thessaly, Greece;3Dept of Hematology, University Hospital of Larissa, Thessaly, Greece;4Dept. of Clinical Nutrition, University Hospital of Larissa, Thessaly, Greece

Background: A reliable assessment of nutritional risk
in patients with advanced cancer, although subjective, is the
cornerstone of an
effective intervention. Sarcopenia is an objective
measurement and the major feature of cachexia which adversely affects
patients’
quality of life and survival. Our aim was to evaluate the
correlation of the two most frequently nutritional assessment tools
used in oncology, Mini Nutritional Assessment (MNA) and
Patients Generated Subjective Global Assessment (PG-SGA), with Lumbar
Skeletal-Muscle index (LSMI) and with Fat Free Mass (FFM).

Methods: Totally, 129 patients [97 (75.2 %)
males, median age (range) 67 (39–81)] with stage IV primaries of the
lung and the upper
GI were eligible. Demographics and other baseline
characteristics were recorded. MNA and PG-SGA were completed before the
onset of systemic therapy. Slice-O-Matic software V4.3
(Tomovision, Montreal, Canada) was used to analyzed CT images at the
level of the 3rd lumbar vertebra (L3) as previously
described by other investigators. Cross sectional area of muscles
(measured
in cm2) at that level was calculated and LSMI (measured in cm2/m2) was produced after normalizing this value for stature. Total body FFM (measured in kg) was also estimated from the muscle
cross-sectional area at L3.

Background: Gastrointestinal (GI) cancer patients are
extremely susceptible to cachexia, which negatively affects quality of
life and
survival. The APCmin + mouse is a valuable model to study
spontaneous development of intestinal/colorectal cancer and cachexia,
yet it is complicated by heterogeneity in tumor
onset/growth, as well as difficulties in quantifying muscle wasting and
GI
tumor burden in the live animal. In this study, we have
developed combined magnetic resonance imaging (MRI) and [F-18]
fluorodeoxyglucose
(FDG) positron-emission tomography (PET) to non-invasively
monitor the progression of muscle wasting related to GI tumor burden
in the APCmin + mouse.

Methods: Male APCmin + (N = 12) and littermate WT controls (N
= 10) were studied. MRI and FDG-PET static scans were performed at 2, 3,
4, and 5 months of age, to monitor muscle volume
and tumor metabolism, respectively. Ex-vivo histopathology
was performed in age-matched APCmin + and WT controls from the
same breeding cohort. Statistical comparisons were performed
using linear mixed-model (LMM) analysis and post-hoc testing
with Fisher’s LSD. P < 0.05 was considered significant.

University of Cambridge, Cambridge Research Institute, Cancer Research UK

Cachexia is known to be one of the final
common clinical processes in end-stage malignancies, malabsorption
diseases, some
chronic infections such as HIV and some end organ diseases
such as chronic obstructive pulmonary disease (COPD). Death or
increased morbidity can occur in up to 50 % of patients
with advanced cancer who experience cachexia. No reliable molecular
marker for cachexia is currently described or established in
clinical practice.

We used quantitative liquid
chromatography-tandem mass spectrometry (LC-MS/MS) to measure 34
modified amino acids in the serum
of 12 patients with pancreatic adenocarcinoma (PAC) (5
patients without cachexia and 7 patients with cachexia). Amino acids
were modified using the EZ:Faast amino acid analysis
procedure consisting of a solid phase extraction step followed by
derivatisation
to chloroformates.

The results were compared to amino acid
concentrations in the serum of patients with cachexia and chronic
obstructive airway
disease (COPD). Several amino acid concentrations were
significantly altered in patients with COPD and cachexia but not
patients
with pancreatic cancer (serine, sarcosine, tryptophan, BCAAs
and 3-methylhistdine; data not shown). Increased γ-aminobutyrate
(GABA) levels were specific to cachexia in patients with
pancreatic cancer. Metabolomic biomarkers could be exploited as a
way of monitoring treatment efficacy, tumour recurrence, and
suitability for intervention in patients with pancreatic cancer
experiencing cachexia.

Cancer cachexia is the loss of body weight
(both lean and fat mass) that occurs in about 50 % of cancer
patients despite adequate
alimentation, and leads to reduced tolerance to cancer
treatment and increase morbidity and mortality. The molecular mechanisms
of cancer cachexia have not been fully elucidated and there
are no approved drugs that effectively prevent or reverse cachexia.
Both of these gaps would be facilitated by appropriate mouse
models of cancer-induced cachexia. Since the response of the
mouse to the tumor (cachexia) and interventions vary between
mouse strains, the purpose of this study was to compare the degree
of cachexia induced by the colon-26 (C26) adenocarcinoma in
adult male Balb/c and CDFI mice in the absence or presence of
the anabolic agent formoterol. Adult Balb/c and CDF1 mice
(14 weeks old) were inoculated subcutaneously with either 5 × 106
C26 cells in 50:50 matrigel:PBS vehicle or an equal volume of the
vehicle alone, concurrent with treatment with or without
formoterol at 2 mg/kg/day in drinking water. Body
weight, food intake and tumor growth were monitored 3× weekly and after
21 days, the mice were euthanized and skeletal muscles
and visceral organs dissected out and weighed. In Balb/c and CDF1 mice,
muscle weights declined by 22.9 % and 15.60 %,
respectively, compared to PBS control. Furthermore treatment with
formoterol
ameliorated C26-induced muscle atrophy by 37.81 % in
Balb/c compared with 28.97 % in CDF1 mice. These findings suggest
that
Balb/c mice are the better strain for C26-induced cancer
cachexia research as they offer a more suitable window for therapeutic
intervention.

Efficacy and safety of a two drug-combination regimen for cancer-related cachexia in the clinical practice

Department of Medical Oncology, University of Cagliari, Cagliari, Italy

Background and aims: To test the safety and efficacy
of a two-drug combination (including nutraceuticals, i.e. antioxidants)
with carnitine +
celecoxib for the treatment of cancer-related
anorexia/cachexia syndrome (CACS) in the clinical practice. Primary
endpoints:
safety, increase of lean body mass (LBM) and improvement of
quality of life. Secondary endpoints: increase of physical performance
(tested by grip strength and 6-min walk test, 6MWT) and
decrease of inflammation (assessed by serum levels of IL-6 and Glasgow
prognostic score, GPS).

Results: From June 2011 to April 2012, 50 patients
with advanced cancer (all stage IV) at different sites were enrolled: 40
completed
the treatment and were evaluable (mean age 63.8 ± 9.6, range
32–81 years). Results showed a significant increase of LBM (by
dual-energy X-ray absorptiometry and by L3 computed
tomography) from baseline as well as physical performance assessed by
6MWT. Quality of life (assessed by EORTC-QLQ-C30 and EQ-5D)
also improved significantly. ECOG PS and GPS decreased significantly.
The treatment was safe, no grade 3–4 toxicities occurred and
no patient had to discontinue the treatment due to severe adverse
events.

Conclusions: The results of the present study confirm
the efficacy and safety of the two-drug combination regimen previously
shown in
a randomized clinical trial (Madeddu et al, Clinical
Nutrition 31:176–182, 2012). Therefore, this simple, feasible,
effective,
safe, with favorable cost-benefit profile, two-drug approach
could be suggested in the clinical practice as a treatment for
CACS.

1Alberta Institute for Human Nutrition, Faculty of Agriculture, Life and Environmental Sciences, University of Alberta, Edmonton,
Alberta, Canada;2Dept. Kinesiology, Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Ontario, Canada;3Dept. Oncology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada

Introduction: The role of cytokines in evoking muscle loss in cancer cachexia is often highlighted, and interference with inflammatory
pathways cited as mechanism for the benefits of EPA on muscle mass, however evidence from human studies is limited.

Objective: To relate change in muscle mass to plasma
levels and change in cytokines (IFN-γ, IL-10, IL-12p70, IL-1β, IL-6,
IL-8 and TNF-α)
measured at baseline and at the end of chemotherapy
treatment in non-small cell lung cancer patients who were supplemented
or not supplemented with fish oil.

Methods: Patients were followed from time of
diagnosis until completion of platinum based doublet therapy
(~3 months). Patients received
4 capsules of fish oil per day (2.2 g EPA + 240 mg
DHA; n = 16) or no intervention (n = 24; standard of
care). Skeletal muscle cross-sectional area was evaluated using lumbar
computed tomography (CT) images
taken for diagnostic purposes. Change in muscle was
expressed as % change from the initial CT scan and divided by the number
of days elapsed between the 2 CT images. Plasma cytokines
were quantified at baseline and the last day of chemotherapy using
commercially available ELISA kits.

Results: Baseline demographics were similar in both
groups, pooled characteristics: 53 % male, age 64 ± 8.7 years,
BMI 26.9 ± 5.2,
6 month weight history −4.9 ± 6.5 %. No
relationships between change in muscle and IFN-γ, IL-10, IL-6, IL-1β or
IL-12p70 were
observed in either group. Change in IL-8 and TNF-α during
chemotherapy were modestly correlated with muscle rate of change
(r = −0.40 and −0.36, respectively, p = 0.02). Plasma cytokine levels did not change significantly over the 3 month time period in the fish oil or standard of
care group.

Conclusions: Cytokines may not be a major driver of muscle loss and alternate mechanisms apart from reducing pro-inflammatory cytokines
may be responsible for the observed effect of fish oil on preservation of muscle mass.

1Sør-Trøndelag University College, Trondheim, Norway;2Norwegian University of Science and Technology, Trondheim, Norway;3. University of Edinburgh, UK,4Cantonal Hospital, St. Gallen, Switzerland,5Haukeland University Hospital, Bergen, Norway

Cachexia is a common feature of many patients
at a terminal stage of cancer. The condition is believed, at least in
part,
to be caused by improper regulation of catabolic processes.
Lysosomal degradation via autophagy is the principal catabolic
processes employed by cells to clear damaged proteins and
organelles, as well as to mobilize metabolites during low-nutrient
conditions. Despite the importance of autophagy in cellular
degradation, a defined role for the process has not yet been established
in cachectic patients. We explores whether cancer cachexia
can be caused by systemically accelerated autophagy and hunt for
the potential mechanism(s) causing increased autophagy flux.
We have established a cellular autophagy flux bioassay where
the process can be quantified in non-cancerous cells using
flow cytometry. Using this bioassay, we find that cancer cells
known to induce cachexia in mice accelerate autophagy in the
reporter cells. Induced autophagy in the reporter cells is observed
both in co-cultures and by exposing the reporter cells for
conditioned media from the cancer cells. Importantly, by screening
serum samples from cancer patients, we find that more than
25 % of the serum samples are able to induce autophagy in the
reporter
cells. Together, our findings support the notion that
tumor-derived signaling substance(s) may accelerate autophagy in normal
cells and may contribute to increased catabolism in cancer
cachexia.

Results: Muscle gain was observed in 84.2 % of
patients after initiating selumetinib; mean overall gain of total lumbar
muscle cross
sectional area was 13.6 cm2/100 days
(~2.3 kg on a whole body basis). Cholangiocarcinoma patients who
began standard treatment were markedly catabolic,
with overall muscle loss of −7.3 cm2/100 days (~1.2 kg) and by contrast only 16.7 % of these patients gained muscle.

Conclusion: Our findings suggest the potential of MEK and putatively interleukin-6 as a target for cachexia therapy.

A comparative study of gene expression changes in
skeletal and cardiac muscle from the colon 26 carcinoma mouse model of
cachexia:
identification of common molecular targets for future
intervention strategies

Angie M. Y. Shum1, Timothy C. Tan1, 2 and Patsie Polly1

1Inflammation and Infection Research Centre, Department of Pathology, School of Medical Sciences, Faculty of Medicine, University
of New South Wales, NSW, Australia, 2052

Cancer cachexia is a highly debilitating
paraneoplastic disease observed in more than 50 % of patients with
advanced cancers
and directly contributes to 20 % of cancer deaths.
While loss of skeletal muscle is a defining characteristic of patients
with cancer cachexia; pathology in heart has only recently
been demonstrated in animal models of cachexia. In this study,
we have compared the gene expression patterns governing
sarcomeric structural degradation and substrate metabolism in skeletal
and cardiac muscle. Common gene expression patterns were
also seen for skeletal and cardiac muscle due to cancer cachexia.
Of particular interest are certain genes involved in
substrate metabolism including proliferative activated receptor, gamma,
coactivator 1 (PGC1) β and the genes involved in
autophagy-lysosomal degradation. However, there were also distinctive
gene
expression patterns seen in each tissue including the E3
ligases of the ubiquitin-proteasome system suggesting different cellular
breakdown responses secondary to the chronic inflammatory
stimulation during cancer cachexia. We propose that gene expression
profiling may be a useful, initial step in the
identification of potential molecular targets common to both types of
muscle
which may serve as therapeutic targets to prevent muscle
breakdown in these tissue.

Doxorubicin (DOX) is a highly effective
antitumor agent widely used in the treatment of solid tumors and
hematologic malignancies.
However, DOX has been shown to induce deleterious effects in
skeletal muscle. Numerous studies have attempted to identify
molecular mechanisms responsible for DOX myotoxicity.
Nevertheless, a complete understanding of DOX-mediated muscle toxicity
remains elusive. The principal mechanism believed to cause
DOX-induced toxicity is increased mitochondrial reactive oxygen
species (ROS) production leading to the induction of
proteolysis and apoptosis. Thus, its clinical use is limited due to
drug-induced
cellular toxicity. Hence, developing a countermeasure to
prevent DOX’s cytotoxicity is important. Therefore, we tested the
hypothesis that treatment with a mitochondrial targeted
antioxidant would protect skeletal muscle from DOX-induced dysfunction.
Cause and effect was determined by preventing DOX-induced
mitochondrial ROS emission in rats using a novel mitochondrial targeted
antioxidant (SS-31). Importantly, treatment with SS-31
resulted in a significant attenuation in the DOX-induced accumulation
of 4-HNE modified proteins. In addition, compared to
untreated DOX animals, DOX animals treated with SS-31 showed a
significant
sparing of muscle cross-sectional area. Finally, prevention
of mitochondrial ROS emission in DOX administered animals was
also sufficient to inhibit DOX-induced increases in
apoptosis. These data confirm that the mitochondria are the dominant
source
of DOX-induced ROS production in skeletal muscle and that
inhibiting mitochondrial ROS emission is sufficient to protect the
skeletal muscle from DOX-induced muscle atrophy and
apoptosis.

A mitochondria-targeted antioxidant protects against activation of autophagy and the proteasome system during disuse atrophy

Increased production of mitochondrial
reactive oxygen species (mROS) promotes disuse skeletal muscle atrophy.
Indeed, our
laboratory has demonstrated that a mitochondria-targeted
antioxidant is sufficient to prevent skeletal muscle atrophy induced
by hindlimb immobilization. Four proteolytic systems
contribute to muscle wasting during prolonged disuse. Both the calpain
and caspase-3 systems are activated in immobilized skeletal
muscle by increased mitochondrial ROS emission. It remains unknown
if increased mROS emission is required to activate autophagy
and the ubiquitin-proteasome system in skeletal muscle exposed
to prolonged periods of inactivity. These experiments tested
the hypothesis that increased mROS emission is required for activation
of both autophagy and the ubiquitin-proteasome system in
skeletal muscle during 7 days of immobilization. As expected, SS-31
treatment prevented the casting-induced increases in ROS
emission from permeabilized soleus and plantaris muscle fibers. Similar
to previous reports, SS-31 treatment prevented the
casting-induced atrophy of both the soleus and plantaris muscles.
Importantly,
treatment of ambulatory control animals with SS-31 did not
alter muscle fiber size. Casting activated the proteasome system,
as evidenced by increases in mRNA expression of MuRF-1 and
atrogin-1 in the soleus muscle and atrogin-1 in the plantaris muscle.
Treatment of animals with SS-31 prevented inactivity-induced
increases in E3 ligase expression in both the soleus and plantaris
muscles. The autophagy system was also activated in both
muscles during casting as indicated by increases in the ratio of
LC3 II/I. Further, cathepsin L mRNA expression increased in
both muscles following 7 days of casting and SS-31 treatment
prevented
these increases in autophagy biomarkers. In conclusion,
these results indicate that the proteasome system and autophagy system
are sensitive to mROS emission during disuse atrophy and
confirm that mROS are important signaling molecules in skeletal muscles
exposed to prolonged periods of inactivity.

Limb and respiratory muscle dysfunction in a murine model of cancer cachexia

Approximately 50 % of cancer fatalities
are associated with cachexia and half of these deaths are attributed to
muscle dysfunction
secondary to excessive skeletal muscle wasting. While it is
tempting to assume that muscle function declines in direct proportion
to the loss of muscle mass, reports of a selective loss of
the motor protein myosin and extensive sarcomeric disarrangement
in muscles of cachexia animals suggest otherwise. We tested
the hypothesis that force deficits in cancer cachexia cannot be
attributed solely to a loss of skeletal muscle tissue. Lewis
lung carcinoma (LLC) cells were injected into the left thigh
of C57BL/6 mice (0.75 × 106 cells/animal).
Control mice received an equal volume injection of growth media. Tumors
were observed in all LLC treated animals
at 21 and 25 days post-inoculation. Functional
properties of extensor digitorum longus (EDL) and soleus muscles
(isolated
from the right, non-injected hindlimb), and muscle strips
dissected from the diaphragm, were determined ex vivo. EDL muscles
showed an earlier and a quantitatively greater loss in mass,
physiological cross-sectional area (pCSA), and peak tetanic force
compared to soleus muscles. At 25 days
post-inoculation, EDL muscles showed a significant reduction in force
normalized to
muscle pCSA. This reduction in specific force was not
trivial, accounting for ~40 % of the total force deficit of the
muscle.
LLC did not affect the twitch force to tetanic force ratio,
suggesting normal Ca2+-release and -activation. Similar
results, i.e. a reduction in specific force and a normal twitch to
tetanic ratio, were observed
for diaphragm muscle strips of LLC treated mice. These
findings indicate that a mass-independent component can make a
substantial
contribution to the muscle dysfunction that characterizes
cancer cachexia. This intracellular component appears to lie downstream
of Ca2+ release, most likely at the level of the actomyosin cross-bridges.

The mechanisms of death in advanced cancer
are frequently unknown. Estimates of cardiovascular contributions to
death in cancer
sufferers have varied from 10 % to 50 %. End-stage
cancer patients may not receive detailed cardiac evaluation and
abnormalities
in CV function or structure may be put down to coincident
risk factors or the adverse effects of chemotherapeutic agents.
Recent research has discovered specific cardiac
abnormalities and dysfunction in animal models of cancer and reports of
cardiac
abnormalities being common in human cancer sufferers. With
unknown cause of death or sudden death being common in cancer the
possibility of heart related mortality and morbidity is
likely.

This may lead us to consider the role
cardiovascular drugs may play in treating cancer patients. Recent
retrospective reports
have showed the use of beta-blockers in cancer (for
non-cancer related conditions) has been associated with reduced cancer
progression or metastases and reduced mortality. The precise
mechanisms remain unclear but the inhibition of metastatic spread
and protecting a heart damaged by the consequences of cancer
and protecting against cancer related cachexia are all possible
mechanisms.

Therapeutically, a phase 3 trial of ACE
inhibitor Imidapril showed a significant reduction in the rate of weight
loss in both
non-small cell lung and colorectal cancer patients but not
in pancreatic cancer. During the trial patients receiving Imidapril
lost a further 1.91 lbs (0.868 k) on average while
those on placebo lost 2.68 lbs (1.218 k). The trial would
have been positive
in the first two cancer types but the lack of efficacy in
pancreatic cancer reduced the average result and led to the trial
just missing its primary endpoint. One of the problems may
have been that in the 6 months prior to starting the trial the
average patient had lost 15 % or an average of
24 lbs (10.9 k) of bodyweight, so that these patients may have
been too advanced
before treatment was started. A confirmatory phase 3 trial
omitting pancreatic cancer was commenced, but subsequently put
on hold as the sponsor concentrated on its non-cachexia
portfolio.

The fourth generation beta blocker, MT-102,
has been shown to improve survival in a cancer model and to reduce
cachexia. In
addition in an ageing rat sarcopenia model it led to
significantly improved food intake and weight gain, particularly lean
mass combined with loss of body fat. In addition it improved
anabolic and catabolic protein signalling. The ACT-ONE trial
is testing the effect of the fourth generation beta blocker
(10 mg bd dose) MT-102 in comparison to placebo on the rate of
weight change over a 16 week period in patients with
cachexia related to underlying stage III and stage IV colorectal or
non-small
cell lung cancer. It has recruited more than 50 % of
its target and is estimated to complete in June 2013, aiming for the
study of 132 patients from Europe, India and Malaysia.

Oral Serum-Derived Immunoglobulin as a Potential Therapy for Cachexia: Improved Growth, Nutritional Status, and Reduction
of GI Inflammation in Animals and Humans

Numerous non-clinical studies of
serum-derived bovine and porcine immunoglobulin (Ig) isolates (SBI)
consistently demonstrate
positive effects across multiple species on growth, food
intake, and nutritional status in animal populations with inflammation.
This suggests a role for SBI as a medical food to augment
traditional medications.

SBI dietary supplementation must be
non-digestible and able to reach the GI tract to benefit an
immunocompromised or otherwise
dysfunctional GI mucosa. While the exact mechanism of action
remains unknown, non-clinical and clinical studies demonstrate
that Ig survives initial digestive processes, providing
improvement in GI function and morphology. This includes increased
absorption, reduced permeability and mitotic activity,
increased villus heights, as well as improved weight gain and bone
density among animals treated with Ig supplements. Further,
early studies in patients with malnutrition or HIV enteropathy
found statistically significant improvements in nutrient
retention and GI symptoms. These data suggest a potential role for
SBI in the treatment of patients with cachexia.

Safety and efficacy data from animals, as
well as adult and pediatric patients for up to 8 months support a
role for SBI dietary
supplementation to inhibit cytokine activity, thus reducing
gut inflammation with resultant improvements in absorption, more
efficient nutrient and protein utilization, increased lean
weight gain, muscle mass and bone density. The implications for
cachexia patients suggest strongly the need for additional
research.

Muscle wasting syndrome (cachexia) is one of
the major causes of death in patients affected by deadly diseases such
as cancer,
AIDS, COPD and sepsis. These individuals lose skeletal
muscle mass due to a decreased rate of synthesis and enhanced
degradation
of muscle proteins. Whereas many of the key mediators of
this syndrome have been identified, there are no effective
anti-cachectic
treatments available to date. Here we show that Pateamine A
(PatA), a known inhibitor of translation initiation, prevents
muscle wasting in a dose-dependent manner. A low dose of
PatA blocks the loss of myotubes caused by treatment with the
proinflammatory
cytokines IFNγ and TNFα. In vivo PatA not only prevents
TNFα/IFNγ-induced muscle wasting but also interferes with muscle loss
triggered by the C26-adenocarcinoma tumours. Surprisingly,
although high doses of PatA abrogate translation initiation in
muscle fibers, a low dose of PatA reverses muscle atrophy by
reestablishing general translation to its normal level. This
selectivity depends on the 5’UTR of iNOS which, unlike the
5’UTR of MyoD, responds to PatA by promoting the recruitment of
the iNOS mRNA to stress granules, where it is maintained in a
translationally repressed state. Collectively, our data provides
a proof of principle that non-toxic doses of compounds such
as PatA could be used as novel drugs to combat cachexia-induced
muscle wasting.

1AVEO Pharmaceuticals,2Michael E DeBakey VAMC and Baylor College of Medicine

Background: Cachexia is associated with increased
inflammatory markers and decreased survival in cancer. A number of such
inflammatory
cytokines have been associated with poor prognosis in
several cancer types but their role in cachexia is not well-understood.

Results: GDF-15, IL-6 and IL-8 were increased in CC
vs. other groups. Activin and G-CSF were significantly upregulated in CC
vs. Co.
Subset analyses showed that GDF-15, Activin A and IL-8 are
increased in CC vs. CNC in lung cancer patients and that GDF-15,
IL-6 and IL-8 are increased in CC patients treated with
platinum-based chemotherapy.

GDF15, IL-6 and IL-8 levels significantly
correlate with 6-month weight loss and with IL-1ra, IL-2, IL-4, IL-9,
IL-10, IFN,
MCP-10, MIP-1a, MIP-1b, TNF-a, VGEF and Activin A in cancer
patients. Analysis in a subset of patients showed that CC had
lower grip strength, aLBM, and fat mass; and that ECOG and
KPS were lower in CC and CNC compared to controls. GDF-15 and IL-8
correlated negatively with aLBM, HGS and fat mass. Activin
correlated negatively with aLBM.

Conclusion: The inflammatory cytokines Activin A,
GDF15, IL-6 and IL-8 are associated with weight loss, decreased muscle
mass and strength
and poor survival in cancer patients. These cytokines may
serve as prognostic indicators in cancer patients and present novel
therapeutic targets for treatment of cancer cachexia.

Cachexia-anorexia syndrome is a
life-threatening aspect to many diseases, in particular many forms of
cancer. Hyperactivity
of the central melanocortin system appears to be a common
factor in most, if not all, forms of experimentally-induced cachexia.
In addition, recent evidence indicates that the lethargy
(lack of activity) associated with cachexia is not melanocortin system
mediated, but rather due to suppression to the central
orexin system. Thus, an ideal anti-cachexia drug would combine the
properties of a melanocortin antagonist and orexin system
agonist or activator.

Previous attempts to develop melanocortin
drugs failed due to cardiovascular side-effects. Analyzing a series of
melanocortin
ligands with in vivo assays demonstrated the dissociation of
melanocortin from cardiovascular activity. The melanocortin
pharmacophore
(HFRW) contains a cardiovascular system activating
RFamide-like pharmacophore: the RW sequence. This suggested that
appropriate
derivatives free of cardiovascular activity might be
possible. The challenge was how to suppress or “hide” the cardiovascular
activity mediated by the overlapping pharmacophore.

We first made a detailed investigation of
melanocortin cardiovascular actions, using arterial pressure, heart
rate, and the
electrocardiogram. The melanocortin ligands produced blood
pressure and heart rate effects that replicated the actions of
RFamide peptides in different experimental models. The
electrocardiograms modeled the clinical presentation of “sick sinus
syndrome” atrioventricular blockade and sudden cardiac
arrest. Thus, the cardiac RFamide system may have an etiological role
in these disorders.

We then designed and synthesized melanocortin
peptide antagonists with an enzymatically stable C-terminal extension.
These
compounds lacked cardiovascular activity, produced a
reversal of cachexia in an aggressive experimental cancer model,
suppressed
cachexia-induced lethargy, and were orally active. Our lead
compound is a potential candidate for a clinically useful anti-cachexia
therapeutic.

Existing data show that NF-kappaB signaling
is a key regulator of cancer-induced skeletal muscle wasting. However,
the identification
of the components of this signaling pathway and of the NF-κB
transcription factors that regulate wasting is far from complete.
In muscles of C26 tumor bearing mice, overexpression of d.n.
IKKβ blocked muscle wasting by 68 %, the IκBα-super repressor
blocked wasting by 41 %, and d.n. p65 blocked wasting
by 20 %. In contrast, overexpression of d.n. IKKα or d.n. NIK did
not
block C26-induced wasting. Genome-wide mRNA expression
arrays showed upregulation of many genes previously implicated in muscle
atrophy. To test if these upregulated genes were direct
targets of NF-κB transcription factors, we compared genome-wide p65
or p50 binding to DNA in control and cachectic muscle using
ChIP-sequencing. Bioinformatic analysis of ChIP-seq data comparing
chromatin isolated from control and C26 muscles showed
increased p65 and p50 binding to some regulatory genes and to structural
genes, many of which are involved in skeletal muscle
development. However, there was no increase in the binding of p65 or
p50 to putative atrophy genes. The p65 and p50 ChIP-seq data
are consistent with our finding only a small increase in protein
binding to an NF-κB oligo in a gel shift assay and a minimal
change in binding to an NF-κB oligo in a transcription factor
plate assay. The multiplex transcription factor assay did
however, show marked increases in C26 muscle nuclear protein binding
to SMAD, C/EBP, GR, CREB, and ATF2 (CREB2) oligos. Taken
together, these data support the idea that although genetic inhibition
of IKKβ and IκBα blocks cancer-induced wasting, the
downstream NF-κB transcription factors may not play a major role. Other
transcription factors we found showing increased binding in
C26 cachectic muscle may be important regulators of wasting, possibly
induced by IKKβ. These data are consistent with the growing
body of literature showing many NF-κB-independent substrates of
IKKβ and IκBα, and we propose that these substrates are some
of the mediators of cancer-induced muscle wasting.

Signaling mechanisms in cancer cachexia: role of TRAF6

Ashok Kumar, Pradyut K. Paul, and Sajedah M. Hindi

Department of Anatomical Sciences and Neurobiology, University of Louisville School of Medicine, Louisville, KY 40202, USA

Skeletal muscle atrophy is a major cause for
morbidity and mortality in many conditions including cancer, starvation,
and
disuse. The ubiquitin-proteasome and autophagy-lysosomal
systems are the two major proteolytic systems involved in regulation
of both physiological and pathological muscle wasting.
However, the signaling mechanisms leading to the activation of these
proteolytic systems have just begun to be elucidated. Tumor
necrosis factor receptor (TNFR)-associated factor 6 (TRAF6) is
an important adaptor protein involved in receptor-mediated
activation of various signaling pathways in response to cytokines
and tumor products. TRAF6 also possesses E3 ubiquitin ligase
activity causing lysine-63-linked poly-ubiquitination of target
proteins. Our recent studies have uncovered a novel role of
TRAF6 in activation of various proteolytic systems and eventual
loss of skeletal muscle mass in catabolic states.
Muscle-wasting stimuli such as cancer growth, denervation, or starvation
augment the expression as well as the auto-ubiquitination of
TRAF6 leading to downstream activation of major catabolic pathways
in skeletal muscle. Muscle-specific depletion of TRAF6
preserves skeletal muscle mass in a mouse model of cancer cachexia,
starvation, and denervation. Inhibition of TRAF6 also blocks
the expression of the components of the ubiquitin-proteasome
system (UPS) and autophagosome formation in atrophying
skeletal muscle. In addition, our study provides the first evidence
that TRAF6 mediates the activation of endoplasmic reticulum
stress and unfolding protein response pathways during starvation-induced
muscle atrophy. Finally, our experiments suggest that lysine
63-linked autoubiquitination of TRAF6 is essential for its regulatory
role in muscle wasting. Collectively, our study provides
strong evidence that blocking TRAF6 activity can be used as a
therapeutic
approach to preserve skeletal muscle mass and function in
different catabolic conditions.

STAT3 is a promoter of cytokine-induced muscle wasting: implication of posttranscriptional regulation

Cachexia, characterized by excessive weight
loss and skeletal muscle deterioration, is a disorder that often affects
individuals
with cancer. Cachectic patients experience loss of skeletal
muscle mass due to decreased synthesis and enhanced degradation
of muscle proteins. Although 20 to 50 % of all
cancer-related deaths are due to consequences of this condition, no
efficient
treatment is available at this time. Pro-inflammatory
cytokines such as TNFα and IFNγ have been shown to mediate
cancer-induced
muscle wasting through the activation of the transcription
factor NF-κB. One of the principle effectors of NF-κB-mediated
muscle wasting is IL-6, a cytokine normally secreted by
immune cells to defend against infection. IL-6 has been shown to mediate
the loss of muscle by inducing the phosphorylation and thus
activation of STAT3. The posttranscriptional regulation of many
short-lived mRNAs that encode pro-cachectic cytokines,
including IL-6, involves AU-rich elements (AREs) found in the 3’UTR.
These AREs mediate the stability, cellular localization and
translation of their host messages through association with ARE-Binding
proteins, such as HuR. Here we show that STAT3 mRNA is a
novel HuR target during IT-induced muscle wasting. We show that HuR
associates both in vivo (IP coupled to RT-PCR) and in vitro
(gel shift) with the STAT3 mRNA in cytokine-treated muscle fibers.
Although cytokines increase STAT3 mRNA and protein levels in
muscle cells, the knockdown of HuR decreases the expression of
STAT3 protein and mRNA. The importance of these findings is
highlighted by our observations showing that cytokine-induced
muscle wasting is delayed by inhibiting the activity of
STAT3. Our data demonstrate that STAT3 is a key player in
cytokine-induced
muscle wasting and that this effect is dependent on
HuR-mediated stabilization of STAT3 mRNA.

Recent studies showed that physical activity
after cancer diagnosis ameliorates the prognosis, although the underling
mechanisms
are still poorly understood. Cachexia, experienced by most
cancer patients, is a negative prognostic factor, interfering with
therapy and worsening quality of life. With the aim to
delineate the pathways involved in exercise-mediated rescue of cachexia,
we investigate the effects of spontaneous physical activity
(wheel running) in colon carcinoma (C26)-bearing mice. All major
diagnostic criteria for cachexia are reversed by exercise,
including rescue of body weight, muscle atrophy and fatigue, ultimately
leading to increased survival. In order to assess whether
muscle contraction plays a role in the exercise-mediated rescue
of cachexia, we denervated one limb of (C26)-bearing mice
and assessed muscle mass following spontaneous wheel running.
Interestingly,
muscle innervations and/or contraction are required for
positive effects exercise exerts on (C26)-bearing mice muscle mass.
At the molecular level, exercise promotes protein synthesis,
by mTOR activation, and attenuates protein degradation, by
downregulating
Atrogin1, in muscle from C26-bearing mice. We propose that
exercise counteracts muscle wasting through a systemic effect,
by both inhibiting catabolic pathways and favouring
satellite cell recruitment into muscle fibers, unveiling a novel
mechanism
of exercise-mediated beneficial effects on cachexia.

1Department of Experimental Medicine and Oncology, University of Torino, Italy; 2Department of Biochemistry and Molecular Biology, University of Barcelona, Spain

Cancer cachexia is a syndrome characterized
by loss of skeletal muscle protein, depletion of lipid stores,
inflammation, anorexia,
weakness, and perturbations of the hormonal homeostasis [1].
In addition to nutritional approaches, exercise training (EX)
was proposed as a suitable tool to manage cachexia, in view
of recent observations suggesting that decreased physical activity
plays a role in the onset of muscle atrophy in cancer
patients [2]. Aim of the present work was to verify if endurance
training
coupled to erythropoietin (EPO) administration could prevent
the wasting process in Lewis Lung carcinoma(LLC)-bearing mice.
LLC mice were got used to a treadmill for 5 days before
tumor injection (106 cells s.c.) and then exercised 5 days/week
(45 min,14 m/min).
At the end of the experimental protocol (28 days after
tumor implantation), tumor-bearing (TB) mice were characterized by
a marked body and skeletal muscle weight loss, resulting in
impaired muscle strength. Moreover, tumor growth induced a dramatic
anemia (50 % hematocrit reduction) and, likely
consequently, heart hypertrophy. The combination of EX with EPO
(100 U/mouse,
i.p., weekly) partially counteracted tumor-induced
hematocrit reduction and prevented heart hypertrophy. Although in the
EX-EPO
group skeletal muscle mass was similar to the sedentary TB
mice, grip strength was significantly increased. Ultrastructural
analysis of the EDL and soleus muscles of TB mice showed
inter-myofibrillar mitochondrial swelling and reduced sub-sarcolemmal
glycogen storage; both alterations were prevented in EX-EPO
mice. Overall, the present data suggest that endurance exercise
can be an effective tool to be included in combined
therapeutic approaches against cancer cachexia. Further ongoing studies
will unravel the molecular mechanisms underlying the
reported effects.

The p97/VCP ATPase complex facilitates the
extraction and degradation of ubiquitinated proteins from larger
structures. We
therefore studied if p97 participates to the rapid
degradation of myofibrillar proteins during muscle atrophy.
Electroporation
of a dominant negative p97 (DNp97), but not the WT, into
mouse muscle reduced fiber atrophy caused by denervation and food
deprivation. DNp97 (acting as a substrate-trap) became
associated with specific myofibrillar proteins and its cofactors, Ufd1
and p47, and caused accumulation of ubiquitinated components
of thin and thick filaments, which suggests a role for p97 in
extracting ubiquitinated proteins from myofibrils during
atrophy. DNp97 expression in myotubes reduced overall proteolysis
by proteasomes and lysosomes and blocked the accelerated
proteolysis induced by FoxO3, which is essential for atrophy. Expression
of p97, Ufd1 and p47 increases following denervation, at
times when myofibrils are rapidly degraded. Surprisingly, p97
inhibition,
though toxic to most cells, caused rapid growth of myotubes
(without enhancing protein synthesis) and hypertrophy of adult
muscles. Thus, p97 restrains post-natal muscle growth, and
during atrophy, is essential for the accelerated degradation of
most muscle proteins.

Methods: The electronic database Medline (via PubMed
and Ovid Medline) was searched to identify original research and review
articles.
The terms “cachexia” or “wasting” or “weight loss” were
used, then in combination with any of the associated disorders (AIDS,
COPD, CHF, Chronic Kidney Failure, RA, Cancer or Neoplasm).
The search limited to English papers (1950–2009).

Results: Of 3344 citations, 585 papers were reviewed,
71 papers included. Different studies used various diagnostic criteria.
In literature
terminology; sundry terms were used interchangeably to
describe cachexia e.g. wasting, malnutrition, and sarcopenia. Metabolic
abnormalities like proteolysis and lipolysis similar amongst
the cachexias.

Conclusions: (1) Clinical and metabolic characteristics were similar across all cachexias; (2) Anorexia and weight loss were common except
in rheumatoid arthritis; (3) Cachexia seemed reversible with dietary intervention.

Systematic Review of C-reactive protein As A Prognostic Indicator in Solid Tumors

Introduction: Serum C-reactive protein (CRP) has been
linked to shorter survival in malignancy. It may help determine
treatment response
and tumor recurrence. We conducted a systematic literature
review to examine the value of CRP to predict prognosis in solid
tumors.

Methods: The following MeSH terms were used:
[(prognosis OR treatment outcomes OR Survival) AND (C-reactive protein
OR CRP) AND (cancer
OR Neoplasm)]. The following electronic databases were
searched: PubMed, EMBASE, Web of Science, SCOPUS, EBM-Cochrane Database.
A quality assessment scoring system was developed and
utilized. Studies with scores <50 % were deemed inadequate and
excluded.

Results: 92 studies made up the final literature
review: 70 % were prospective and 24 % retrospective. The
median quality assessment
(QA) score was 60 (range 50–80). Elevated CRP predicted
prognosis in 78 % by multivariate analysis, and 13 % by
univariate
analysis only. Over half (55 %) of studies were either
in gastrointestinal malignancies or renal cell carcinoma. High CRP
level predicted prognosis in 80 % of the studies in
these two specific tumor groups. Most studies in other tumors suggested
a prognostic role.

Conclusions: (1) CRP seemed valuable as a predictor
of prognosis in some cancers; (2) CRP may have a role in determination
of treatment
response and tumor recurrence; (3) CRP should be more widely
used and investigated for this purpose; (4) Better quality large
studies with standardized study design should define the
role of CRP in prognosis.

Introduction: C–reactive protein (CRP), a
non-specific marker of inflammation may be used for cancer
prognostication. Our objectives were
(1) To look if solid tumors are associated with high CRP;
(2) To evaluate if clinical predictors correlate with CRP in solid
tumors; (3) To see if CRP relates to survival.

Methods: A retrospective review of the Electronic
Medical Record (EPIC) was conducted. Data included multiple CRP
measurements at
a tertiary cancer center (2006–2008). Hematological cancer
diagnoses were excluded. Survival defined as days from the highest
CRP to date of death. CRP value reported in median (25th,
75th percentiles).

Animal models have showed that
ubiquitin-proteasome pathway may be the effector of muscle loss during
cancer cachexia. However,
evidence from clinical studies is still needed to understand
mechanisms involved in cancer induced muscle catabolism in patients.

Patients (n = 17, 64 ± 6 years)
diagnosed with esophageal cancer were undergoing surgery with intent of
resection of the primary tumor.
As a control group, weight stable patients undergoing reflux
surgery (n = 10, 60 ± 7 years) were included. Vastus lateralis
muscle biopsies were taken with a Bergstrom needle. Proteasome, caspase
3, calpains and lysosomal enzymatic activities were
measured by using specific fluorogenic peptide substrates.
Protein expressions were measured by western-blot and coomassie
blue staining was used as a loading control. Differences
between the groups were tested with a Student’s t-test.

In our clinical study, we observed
weight-loss related activation of cathepsins and increased expression of
LC3, a marker
of autophagy flux, in skeletal muscle of cancer patients.
These results suggest that autophagy-lysosomal pathway is involved
in the development of cancer cachexia and might be an
important therapeutic target for fighting cachexia.

Biomarker evaluation and staging in cancer cachexia: are cytokines still relevant diagnostic and treatment aids?

Background: We have provided initial evidencea on the clinical usefulness of the cancer cachexia stages (CCS) proposed by Fearon et alb. However it is still unclearc if particular molecular phenotypes are also associated with these stages, or with relevant clinical outcomes.

Conclusions: Activin A, GDF15, IL-6 and IL-8 appear
to be useful aids for the diagnosis of cachexia stages in advanced
cancer. Because
of their correlation with nutritional and survival outcomes,
these cytokines may also represent useful targets for the treatment
of cancer cachexia.

1Indiana University Simon Cancer Center and2Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA3The Clyde and Helen Wu Center for Molecular Cardiology,4Department of Physiology and Cellular Biophysics, College of Physicians and Surgeons of Columbia University, New York, NY,
USA

Muscle weakness is common in advanced cancers
and is a cause of significant cancer-related morbidity and mortality
yet the
mechanisms of cancer-associated muscle dysfunction are
largely unknown. Ryanodine receptor (RyR1) is the skeletal muscle
sarcoplasmic
reticulum calcium release channel required for
excitation-contraction coupling. RyR1 undergoes remodeling in disease
states
resulting in leaky channels characterized by oxidation and
nitrosylation and loss of the stabilizing subunit, calstabin1.
We hypothesized that impaired muscle function in cancer
could be due to remodeling of RyR1.

We used a mouse model of breast cancer
metastatic to bone during which mice lose significant weight.
Five-week-old female
nude mice were inoculated with MDA-MB-231 cells via
intra-cardiac inoculation and compared to non-tumor bearing controls.
Mice developed osteolytic lesions 12 days after
inoculation. Tumor bearing mice lost significant weight by 4 weeks
(20.5 ± 0.6
vs. 23.2 ± 0.4; p < 0.0002). This was associated with a significant reduction in total body tissue, lean mass and fat in tumor bearing mice,
as assessed by DXA (P < 0.01), with no difference in total body %lean mass or %fat. Muscle specific force production of the extensor digitorum
longus (EDL) muscle was significantly decreased in tumor bearing mice (p < 0.001) and the reduction in muscle force correlated with larger osteolytic lesions (p
< 0.05). In addition, transmission electron microscopy showed
dysmorphic mitochondria in tumor bearing mice. Immunoprecipitation
of RyR1 from EDL of tumor bearing mice showed that RyR1 was
oxidized, nitrosylated and depleted of calstabin1, consistent
with leaky channels. Muscle function was also significantly
impaired in animals harboring small osteolytic lesions visible
by X-ray (p < 0.001) during the early stages of
weight loss and disease progression. Importantly, primary MDA-MB-231
tumors in the mammary
fat pad of mice (without bone metastases) did not lose
weight or exhibit muscle weakness.

Our data show that MDA-MB-231 bone metastases
are accompanied by severe muscle dysfunction and remodeling of RyR1.
Similar
remodeling of RyR1 has been shown to cause muscle weakness
in muscular dystrophies and sarcopenia. Targeted therapy against
leaky RyR1 channels improves muscle function and exercise
capacity in murine models of muscular dystrophy and sarcopenia and
may be an effective therapy for cancer-associated muscle
weakness.

Cancer cachexia is a condition of
unintentional body weight loss through a reduction in skeletal muscle
and adipose tissue
mass. Cachexia is associated with increased morbidity and
inability to treat patients with appropriate chemotherapies. Currently
there are no fully effective treatments for cachexia and
ascertaining molecular targets to maintain muscle mass in cancer
patients is of great importance. Our laboratory has recently
discovered a new isoform of the canonical transcriptional coregulator
PGC-1α referred to as PGC-1α4. PGC-1α4 induces muscle
hypertrophy through increased muscle IGF-1 expression and a reduction
in myostatin expression, thus making it an excellent
candidate to explore for anti-cachexia therapies. The purpose of this
study was to determine if forced expression of muscle
PGC-1α4 can attenuate muscle wasting during cancer-induced cachexia.
Lewis Lung Carcinoma Cells (LLC), an established cachectic
cell line were injected into wild-type and transgenic mice expressing
the PGC-1α4 isoform then studied for 28 days throughout
the progression of cachexia. The gastrocnemius muscle was examined
for gene expression and cellular signaling. PGC-1α4
transgenic mice showed an attenuated loss in body weight, muscle mass
and functional strength after 28 days of inoculation.
Transgenic mice showed a decrease in muscle myostatin gene expression
and increase in IGF-1 corresponding with the reduction in
atrogenes MAFbx1 and MuRF1. Improvements in muscle mass observed
in PGC-1α4 TG mice were associated with increased voluntary
movement throughout the progression of cachexia. In addition,
glucose intolerance, a common pathology during cachexia is
improved in PGC-1α4 transgenic mice. These data show PGC-1α4 can
regulate muscle wasting and improve functionality during
cancer-induced cachexia.

The USP19 deubiquitinating enzyme is required for muscle wasting and regulates both protein synthesis and degradation

1Dept. of Medicine,2School of Dietetics & Human Nutrition,3Dept. of Neurology & Neurosurgery,4Dept. of Biochemistry,5McGill Nutrition Centre, McGill University &6Dept. of Oncology, University of Alberta, Canada

Although enzymes involved in ubiquitin
conjugation have been implicated in atrophying muscle, little is known
about the role
of deubiquitinating enzymes (DUBs). We previously showed
that the USP19 DUB is induced in various conditions of muscle atrophy
including cancer and that silencing of USP19 in muscle cells
protects them from a catabolic stimulus. To test the relevance
of this in vivo, we inactivated USP19 in mice and
characterized the wasting response induced by denervation, fasting,
glucocorticoids
and cancer and also measured expression of USP19 in human
muscle samples. In response to fasting, denervation, dexamethasone,
USP19 KO mice showed 26–39 % less muscle wasting than
WT mice. Myofiber area measurements in the denervation studies confirmed
that this was due to less myofiber atrophy in the KO mice.
In fasting, fractional synthesis rates were 260 % and 135 %
higher
in the KO in the sarcoplasmic and myofibrillar fractions
respectively. In fasting, denervation and cancer, expression of MuRF1
and some autophagy genes in the KO were <50 % that
in WT. USP19 may exert these effects on both protein synthesis and
degradation
by regulating signaling upstream of both processes. Indeed
in the KO, the induction of muscle myostatin upon fasting and cancer
was abolished whilst there were no effects on IGF-1
expression. In muscle samples of patients with cancer (20 with non-small
cell lung cancer and 100 with mostly abdominal cancers),
expression of USP19 correlated with expression of the MURF1 and MAFbx
ligases.

Conclusions: USP19 is required for the catabolic
response in diverse wasting conditions. It suppresses protein synthesis
and enhances
protein degradation (ubiquitin proteasome system and
autophagy) and this appears in part due to induction of myostatin
expression.
These results and its expression in human cancer patients
identify USP19 as a potential drug target in treatment of cachexia.

Satellite cells, composed of a heterogeneous
pool of myogenic stem cells and committed progenitor cells, are crucial
for the
maintenance and growth of adult muscles. Modulation of
satellite cell self-renewal (proliferation) and lineage commitment
(differentiation) affects adult muscle growth and repair in
animal models. Here, similar to what has been reported in Colon-26
cachexia, we observed a large increase in Pax7-positive
cells in Lewis Lung Carcinoma cachexia model. Further analysis showed
that Ki67-positive cell numbers were doubled in the muscle
of LLC tumor-bearing mice, suggesting that the increase in Pax7-positive
cells might be associated with proliferation. Co-staining
for Pax7 and MyoD showed that the majority of Pax7+ cells (~92 %) found in normal muscle co-expressed MyoD, while a drastic decrease in the proportion of Pax7+/MyoD+
cells was observed in LLC tumor-bearing mice. Gene ontological analysis
of microarray data from murine and human cancer cachexia
revealed that muscle contraction and differentiation genes
were the most down-regulated. The expression of myogenic regulatory
factors (MRFs) was also down-regulated in cancer cachexia
models. Overall, our findings revealed that the elevated proliferation
level of muscle progenitor cells and the suppression of
muscle terminal differentiation were highly associated with muscle
wasting in cachexia models, suggesting that blockade of
terminal differentiation of myogenic progenitors may in part contribute
to muscle wasting in cancer cachexia. If so, strategies to
promote differentiation might be a means of preserving muscle mass.

A new cancer cachexia animal model substantiates the causative relationship between cachexia and systemic inflammation

Department of Surgery, Stanford University School of Medicine,1201 Welch Rd. Stanford CA94305, USA

Although previous studies have linked cancer
cachexia to some inflammatory cytokines, the relationship of cachexia
with inflammation
still remains elusive which hampers the development of
effective therapeutic approaches. Part of the reason is lack of
appropriate
animal cancer cachexia models since many of the cachexia
associated debilitation and systemic inflammation related pathogenesis
observed in cancer patients were not reflected in those
early animal models. Thus a clinically relevant cancer cachexia animal
model is urgently needed. Recently we have developed a new
mouse cancer cachexia model (CHX207). After a subcutaneous inoculation
of CHX207 cells (one million), 40 % of mice experience a
loss of more than 7 % total body weight in two successive
days(defined
as cachexia onset by us) by 2 weeks when tumors are
7–10 mm in diameter, and 80 % by 3 weeks. After the onset
of cachexia,
the overall health of mice deteriorated quickly as indicated
by 3–6 % step-wise daily drop of body weight and appearance of
ruffled fur, arched back and lethargy. Most of the cachectic
mice become moribund within 3–10 days following cachexia onset.
Necropsy of moribund mice revealed a variety of pathological
changes among multiple organs including liver, spleen and lung
etc. Consistent with clinical observations in cachectic
cancer patients, systemic inflammation characterized by severe
lymphopenia,
leukocytosis and massive infiltration of neutrophils in
multiple vital organs is found to accompany cachexia. While systemic
inflammation has long been speculated to be one of the major
underlying mechanisms of cachexia, there is no previous experimental
investigation to support this speculation. We substantiated
this speculation for the first time by the demonstration that
cachexia can be reversed by suppressing systemic
inflammation with palliative dose of certain chemotherapy drugs without
inhibition
of tumor growth. Thus we have not only established a new
cancer cachexia model which faithfully recapitulates the debilitating
medical condition in cancer cachexia patients from visible
symptoms to underlying systemic inflammation related pathogenesis,
but also pointed out targeting systemic inflammation with
palliative dose of chemo drug is a promising approach to the treatment
of cancer cachexia.

Background: Cancer cachexia is a catabolic condition
characterized by progressive weight reduction and energy imbalance
associated with
systemic inflammation, elevated CRP & cytokines. While
muscle and fat loss are obvious manifestations of cachexia, it is likely
that the pivotal role of the liver in nutrient uptake,
metabolism and redistribution contributes to dysregulated metabolism
of cachexia.

Methods: Utilising a multi-platform approach
including microarray and MS-based iTRAQ analysis, as well as novel
ATP-binding protein
enrichment technology coupled with label free
MS-quantitation, we have profiled gene and protein expression patterns
of livers
from C26 tumor-bearing mice displaying cachexia. RESULTS.
The transcriptomic and proteomic datasets revealed high correlation
between the three approaches, with very few instances of
incongruity. Pathway analysis utilizing several software packages
indicated that central metabolic processes including lipid
handling, glycolysis/gluconeogenesis, amino-acid metabolism, TCA
cycle and mitochondrial electron transport chain are reduced
in cachectic mice. Linking these metabolic pathways to upstream
regulatory events, transcriptional activation is reduced
within the RXR canonical pathway (e.g. CAR, LXR, FXR, TR, PPARα/δ/γ),
associated with cytokine signalling through activated
JAK/STAT pathway, SOCS3 and IL-1/LPS-BP signalling. Repressed expression
of genes and proteins in key energy generation pathways is
counter-intuitive to the expected role of the liver in settings
of food restriction/weight-loss–i.e. to adaptively utilize
amino acids, carbohydrates & fatty-acids and activate ketone body
production & gluconeogenesis. As a counterpoint to this
dramatic disruption in metabolic pathways, we see enhanced acute phase
protein production and a concomitant increase in protein
translation, potentially mediated through phosphorylated 4E-BP
downstream
of mTOR.

Conclusion: Chronic stimulation of
cytokine-signalling in the liver by distal tumours disrupts metabolic
pathways responsible for maintaining
energy homeostasis. The net outcome of impaired hepatic
processing & supply of nutrients to muscle, fat & other organs
would
contribute to the devastating effects of cachexia.

Background: Cancer cachexia/anorexia is a complex
syndrome involving profound metabolic imbalance leading to muscle
wasting and fat depletion
and is the direct cause of death in 20–30 % of all
cancer patients. Brown adipose tissue (BAT) plays a key role in
thermogenesis
and energy balance and may contribute to the physiological
perturbations associated with advanced cancer including hypermetabolism,
fever and cachexia. Therefore, we investigated the impact of
the IL-6 producing cachectic Colon 26 (C26) tumour on BAT in
mice.

Conclusion: Our findings highlight a role for thermogenic activation of BAT associated with tumour-derived IL-6 as an energetically
wasteful, maladaptive response to anorexia during the development of cachexia.

Background: Involuntary weight loss in patients with
cancer is the hallmark of cancer cachexia. The aetiology of cachexia is
multifactorial
involving loss of skeletal muscle and adipose tissue
associated with high systemic levels of acute phase proteins and
inflammatory
cytokines. While muscle wasting overtly impacts on cancer
patient quality of life, depletion of lipid depots represents a
sustained energy imbalance. Circadian rhythm is important
for the integration of environmental cues, nutritional intake and
physiological activities of organs such as adipose tissue.
In the present study we investigated the impact of the murine cachectic
Colon 26 (C26) carcinoma on white adipose tissue (WAT).

Background: Pancreatic cancer (PCA) is associated
with low quality of life, a prevalence of cachexia, and an unacceptably
high number
of treatment failures. We hypothesized that patients
presenting with advanced PCA display cardiovascular perturbations such
as endothelial dysfunction and exercise limitation.

Methods: We studied 74 patients with PCA and 57
control subjects. All patients underwent a full non-invasive
cardiological examination
including resting electrocardiogram, echocardiography,
treatmill exercise testing, body composition, venous strain-gauge
plethymography,
assessment of a set of biomarkers and assessment of several
pro-inflammatory cytokines.

Discussion: We have shown that patients with PCA
display many aspects of cardiovascular illness. Pro-inflammatory
cytokines may not only
be associated with the development of endothelial
dysfunction but also with loss of lean tissue. Decreases in forced
expiratory
volume in 1 s in our patients with PCA may likewise
point to decreased muscle strength. These characteristics may worsen the
patients’ exercise capacity and therefore may have a role in
the development of fatigue.

Backgrounds: Leptin, anorexigenic hormone involved in
body mass regulation, might play a role in cancer cachexia development.
Hormones
produced by adipocytes are associated with cancer
progression. Elucidating the mechanisms by which obesity may increase
cancer
risk may lead to the identification of treatment and also
prevention targets. We aimed to compare the leptin serum levels
in colorectal cancer patients and healthy individuals and
also to correlate leptin concentration with body mass index.

Material and methods: Eighty-four patients with
colorectal cancer and 80 healthy controls were enrolled and subdivided
according to their BMI
in underweight, normal weight or overweight. Serum leptin
levels were measured as ng/ml by enzyme linked immuno-sorbent assay
(ELISA) method in all subjects.

Results: There were no differences in gender and age. Serum leptin concentration of underweight cancer group was significantly lower
than underweight controls (4.79 ± 3.9 vs. 22.3 ± 21.8) (p = 0.005). On the other hand, on overweight cancer group were higher compared to overweight control (24.8 ± 29 vs. 10.5 ± 15)
(p = 0.022). Between normal weight cancer group and health individuals there were no differences (p = 0.550). Comparing cancer group to the control group, without consider the BMI, we did not find any difference (p = 0.229).

Conclusion: The higher levels of leptin in cancer
obese patients suggest a higher amount of fat mass probably because of
fat free mass
depletion. Our results showed that leptin may play a role in
development and progression of colorectal cancer only in obese
subjects. Key words: leptin, colorectal cancer, obesity

Backgrounds: Obesity is a significant cause of
mortality and diseases like cancer. On the other hand, cachexia, or
pathologic weight
loss, is a significant problem. Despite their differences,
both processes involve neuropeptides and hormones that regulate
food intake and energy expend. Alterations in this mechanism
can lead to obesity or anorexia. Thus far, these peptides have
mainly been studied in animal models but not in cancer
people. The present study aimed to assess the behaviour of anorexigenic
and orexigenic neuropeptides and peripheral signals
(Ghrelin, PYY, NPY and AgRP) in colorectal cancer patients compared to
a healthy group.

Material and methods: 164 subjects were enrolled into
the study: 84 with colorectal cancer and 80 healthy controls. The
peptides and the neuropeptides
were measured by enzyme linked immuno-sorbent assay (ELISA)
method in all subjects.

Results: PYY, NPY and AgRP were lower in the Cancer group. In underweight Cancer subjects the results were the same but in AgRP levels
(p = 0.181). Between normal weight and overweight we found differences in all groups with lower levels in Cancer group. Ghrelin
levels were higher in colorectal cancer patients despite of BMI.

Conclusions: PYY and NPY seem to have the same
regulation and not to be influenced by the BMI. On the other side, AgRP
levels were higher
in cancer patients only among underweight. The most
important finding was that ghrelin were always higher in cancer patients
despite of body mass index.

The behaviour of the peptides leptin and ghrelin, PYY, NPY, CART, AgRP and MSH in gastric cancer patients

Backgrounds: Peptides that regulate food intake have
been studied and associated to some types of cancers. Generally, gastric
cancer
patients tend to be cachectic with low body mass index
(BMI), since most of them have gastrointestinal symptoms such as a
nausea and anorexia. The aim of this study was to
investigate, in gastric cancer patients, the behaviour of some peptides
that regulate food intake.

Methods: Serum ghrelin, leptin, PYY, NPY, AgRP, CART and MSH levels were measured by ELISA (enzyme linked immuno-sorbent assay).
BMI and weight loss, were determined in all subjects studied. The patients had been classified in 3 groups: cachectic group, according to Fearon,2011 (gastric cancer patients in treatment); non-cachectic group (gastric cancer patients that have
already finished the treatment and are gaining weight) and health controls.

Results: among the 127 subjects studied, 19 were in the cachectic group (47 % underweight and 21 % overweight); 28 in the non-cachectic and 80 as health control. PYY, NPY and CART levels were lower in cachectic group followed by non-cachectic. Ghrelin levels, in contrast were lower in the health group (p < 0.001). Leptin, AgRP and MSH did not show any difference between all groups.

Conclusion: Leptin, MSH and AgRP concentrations did
not show any difference in gastric cancer patients (cachectic and
non-cachectic).
Despite of gastric surgery ghrelin levels were still higher
in cachectic group followed by non-cachectic. The concentrations
of PYY and NPY were lower while ghrelin were higher in
cachectic group suggesting a possible mechanism of reversing the
cachexia
process.